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Severe tophaceous gout in a woman with therapeutic non-compliance
Tiago Afonso Costa1,2, Sandra Falcão1,2, Fernando Pimentel-Santos1,2, Jaime Cunha Branco1,2
1Rheumatology Department at Hospital Egas Moniz, Lisboa, Portugal
2CEDOC, NOVA Medical School/Faculdade de Ciências Médicas, Lisboa, Portugal

Article ID: 100010Z14TC2018
doi: 10.5348/100010Z14TC2018CL

Corresponding Author:
Tiago Afonso Costa,
Serviço de Reumatologia,
Hospital de Egas Moniz Rua Da Junqueira 126,
1349-019 Lisboa, Portugal

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How to cite this article
Costa TA, Falcão S, Pimentel-Santos F, Branco JC. Severe tophaceous gout in a woman with therapeutic non-compliance. J Case Rep Images Orthop Rheum 2018;3:100010Z14TC2018.


CASE REPORT

A 67-year-old female presented with large tophaceous gouty arthropathy with diagnosis since 2006. First symptoms occurred in 2004 with polyarticular involvement of the small joints of the hands. She mentioned since 2006 the appearance of gouty tophi in the hands, elbows and feet, initially of small dimensions. She had history of essential hypertension, active smoker and regular consumption of alcohol (20–24 g/day). History of chronic kidney disease or family gout history was unknown. She was medicated with prednisolone 5 mg/day, colchicine 1 mg/day, irbesartan + hydrochlorothiazide 300 + 12.5 mg/day. The patient presented an irregular follow-up in consultation and refusal to take medication with allopurinol. She was hospitalized in April 2015 at the Rheumatology Department of the Hospital Egas Moniz, after progressive worsening in the previous months, by exuberant tophaceous gout in the hands and feet with spontaneous drainage Figure 1 (A and B). Semiologically, it stood out, as large subcutaneous gouty tophi on the back of the right hand (10 cm x 10 cm), back of the left hand, forefoot (10 cm x 10 cm), with multiple tophi of small dimensions in the phalanges of the hands and feet, wrists and elbows. Analytically, uric acid of 9.0 mg/dl. During hospitalization, the importance of smoking and alcohol avoidance was explained. The reintroduction of allopurinol was attempted unsuccessfully, taking into account the vehement refusal of the patient. Considering the context and the risk-benefit relationship, we chose not to try other therapeutic alternatives (febuxostat or anakinra). An antihypertensive therapy switch was made for losartan and amlodipine (antihypertensive drugs that may contribute to the reduction of uric acid). She had hospital discharge forwarded to the plastic surgery appointment.

Keywords: Prognosis, Therapeutic non-compliance, Tophaceous gout arthropathy



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Figure 1(A and B): Severe tophaceous gout in a woman.


DISCUSSION

The tophaceous gouty arthropathy in women is an uncommon disease. In premenopausal women usually associates with a positive family history [1, 2]. On the contrary, postmenopausal is mainly associated with diuretic therapy and chronic kidney disease [1], [2]. In terms of classification, “severe disease” is considered when patients have at least 5 gouty tophi, what happens in severe untreated hyperuricemia lasting for years [3] . The patients who comply with hypouricemic therapy and correct other associated factors (such as diuretics or alcohol abuse) usually have a good course of the disease [1], [2].

The patients with tophaceous gouty without treatment have a progressive worsening disease [1], [2]. They present multiple tophi, some of them large with spontaneous drainage, more frequently in the hands, elbows and feet, which causes a lot of pain, functional limitation and risk of infection [1], [2].

CONCLUSION

These are rare images of a woman with severe tophaceous gout with long-term hyperuricemia and associated with a poor prognosis due to the absence of alcohol abstinence and non-compliance to the therapy with allopurinol.


REFERENCES
  1. Harrold LR, Yood RA, Mikuls TR, et al. Sex differences in gout epidemiology: Evaluation and treatment. Ann Rheum Dis 2006 Oct;65(10):1368–72.   [CrossRef]   [PubMed]    Back to citation no. 1
  2. Dirken-Heukensfeldt KJ, Teunissen TA, van de Lisdonk H, Lagro-Janssen AL. "Clinical features of women with gout arthritis." A systematic review. Clin Rheumatol 2010 Jun;29(6):575–82.   [CrossRef]   [PubMed]    Back to citation no. 2
  3. Vázquez-Mellado J, Cruz J, Guzmán S, Casasola-Vargas J, Lino L, Burgos-Vargas R. Severe tophaceous gout: Characterization of low socioeconomic level patients from México. Clin Exp Rheumatol. 2006 May–Jun;24(3):233–8.   [PubMed]    Back to citation no. 3

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Author Contributions
Tiago Afonso Costa – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Sandra Falcão – Substantial contributions to conception and design, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Fernando Pimentel-Santos – Substantial contributions to conception and design, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Jaime Cunha Branco – Substantial contributions to conception and design, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of Submission
The corresponding author is the guarantor of submission.
Source of Support
None
Consent Statement
Written informed consent was obtained from the patient for publication of this study.
Conflict of Interest
Author declares no conflict of interest.
Copyright
© 2018 Tiago Afonso Costa et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.